Journal of Speech and Hearing Research, Volume 34, 1158-1 168, October 1991
Otitis Media in Early Childhood and Later Language Joanne E. Roberts Division of Speech and Hearing Sciences and Frank Porter Graham Child Development Center University of North Carolina at Chapel Hill
Margaret R. Burchinal Department of Psychology and Frank Porter Graham Child Development Center University of North Carolina at Chapel Hill
Brenda P. Davis Frank Porter Graham Child Development Center Unmversty of North Carolina at Chapel Hill
Albert M. Collier Frederick W. Henderson Department of Pedlatncs and Frank Porter Graham Child Development Center University of North Carolina at Chapel Hill
:
The relationship between early otitis media with effusion (OME) experience and later language development was examined in a prospective cohort study of 30 children from middle-class families and 33 children from low-income families. Ear status was monitored using otoscopy and tympanometry during wellness and illness periods between birth and 3 years of age. Language was assessed using standardized tests and a language sample between 41/2 and 6 years Findings suggested no reliable relationship between early OME experience and later language development. KEY WORDS: otitis media, language development, ear Infections, children
Otitis media with effusion (OME), or middle ear disease, is one of the most common illnesses in young children (Teele, Klein, & Rosner, 1980; Teele, Klein, Rosner, & the Greater Boston Otitis Media Study Group, 1989). Recently, speech-language pathologists and audiologists have focused on OME because of a hypothesized linkage between persistent or frequent OME during early childhood and later language difficulties (Holm & Kunze, 1969; Schlieper, Kisilevsky, Mattingly, & Yorke, 1985; Silva, Chalmers, & Stewart, 1986; Teele, Klein, Rosner, & the Greater Boston Otitis Media Group, 1984). The occurrence of fluctuating mild to moderate hearing loss associated with OME during the formative years of language development is assumed to be responsible for these adverse developmental outcomes. The child who experiences changes in hearing sensitivity can receive a partial or inconsistent auditory signal and thus miss or confuse important auditory information. A child with repeated episodes of OME with varying degrees of hearing loss could then experience changes in the input to the database upon which language develops. Despite this conceptually compelling argument, the existence of an association between OME during the first 3 years of life and later language skills remains controversial because of conflicting empirical evidence and methodological problems of studies (Paradise & Rogers, 1986; Ruben et al., 1989; Ventry, 1980, 1983). Numerous studies have found evidence to support the association between early OME and later language development (e.g., Black et al., 1988; Friel-Patti & Finitzo, 1990; Holm & Kunze, 1969; Schlieper et al., 1985; Silva et al., 1986; Zinkus, Gottlieb, & Schapiro, 1978). These studies have shown that children with a history of early OME as compared to children without a history of OME have poorer receptive language (e.g., Pearce, Saunders, Creighton, & Sauve, 1988; Silva, Kirkland; Simpson, Stewart, & Williams, 1982; Teele et al., 1984; Zinkus & Gottlieb, 1980), expressive language (e.g., Friel-Patti & Finitzo, 1990; Rach, Zielhuis, & van den Broek, 1988; Silva et al., 1986; Wallace, Gravel, McCarton, & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988), less diverse vocabulary (e.g., Holm & Kunze, 1969; Teele et al., 1984), less complex syntax (e.g., Holm & Kunze, 1969; Schlieper et al., 1985; Zinkus & Gottlieb, 1980), and different use of language (e.g., Feagans, Sanyal, Henderson, Collier, & Appelbaum, 1987). Language was assessed
1991, American Speech-Language-Hearing Association
1158
Downloaded From: http://jslhr.pubs.asha.org/ by a Northern Illinois University User on 10/03/2016 Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
70224685/91 /345-1158$01 .00/C
Roberts et al.: Ontis Media and Language
using standardized language tests (e.g., Friel-Patti & Finitzo, 1990; Silva et al., 1982; Wallace, Gravel, McCarton, & Ruben, 1988), language samples (e.g., Schlieper et al., 1985; Teele et al., 1990), and parent report of language development (e.g., Zinkus & Gottlieb, 1980; Zinkus et al., 1978). A relationship between OME and language was reported for infants and toddlers (e.g., Friel-Patti & Finitzo, 1990; Friel-Patti, Finitzo-Hieber, Conti, & Brown, 1982; Wallace, Gravel, McCarton, & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988), preschool children (e.g., Lehmann, Charron, Kummer, & Keith, 1979; Pearce et al., 1988; Rach et al., 1988; Schlieper et al., 1985), and schoolaged children (e.g., Silva et al., 1986; Teele et al., 1990; Zinkus & Gottlieb, 1980; Zinkus et al., 1978). However, other studies failed to support a relationship between early OME and language skills (e.g., Allen & Robinson, 1984; Fischler, Todd, & Feldman, 1985; Lous, FiellauNikolajsen, & Jeppesen, 1988; Wright et al., 1988). Children with a history of OME did not score more poorly than children without a history of OME in receptive language (e.g., Black et al., 1988; Rach et al., 1988; Teele et al., 1990; Wallace, Gravel, McCarton & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988; Wright et al., 1988), expressive language (e.g., Black et al., 1988; Pearce et al., 1988; Silva et al., 1982; Wright et al., 1988), vocabulary (e.g., Brookhouser & Goldgar, 1987; Fischler et al., 1985; Lous et al., 1988; Wright et al., 1988), and syntax (e.g., Feagans et al., 1987; Fischler et al., 1985; Teele et al., 1984). Assessments were made using standardized language tests (e.g., Fischler et al., 1985; Lous et al., 1988; Wright et al., 1988) and language samples (e.g., Feagans et al., 1987; Teele et al., 1990). Children in the studies were infants and toddlers (e.g., Black et al., 1988; Wallace, Gravel, McCarton, & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988), preschoolers (e.g., Pearce et al., 1988; Rach et al., 1988; Wright et al., 1988), and school-aged children (e.g., Fischler et al., 1985; Silva et al., 1982; Teele et al., 1990).
Explanations of Conflicting Findings The conflicting findings in the studies of the relationship between early OME and later language performance may be due to two things: (a) limitations in the methodologies of previous studies (Paradise, 1981, 1983; Paradise & Rogers, 1986; Ruben et al., 1989; Ventry, 1980), in particular the timing of the data collection, research design, and OME documentation procedures; and (b) interactions between OME and other risk factors (Roberts & Schuele, 1990). Table 1 describes previous OME-language studies according to these methodological issues. Methodological Issues Timing of data collection. In the OME-language studies, data were collected either prospectively or retrospectively. In a completely prospective study (e.g., Fischler et al., 1985; Friel-Patti & Finitzo, 1990; Pearce et al., 1988; Teele et al., 1984), from the onset of the study the researcher observed both the OME history and the language of the children;
1159
neither was observed before the beginning of the study. In contrast, in a completely retrospective study, both the OME and language outcomes have occurred before the study began. Some studies combined both retrospective and prospective methods and use an ambispective approach (e.g., Black et al., 1988; Holm & Kunze, 1969; Schlieper et al., 1985); the OME history was collected retrospectively and the language outcomes prospectively. Data in retrospective studies were generally collected through recall of past events or a review of records, and thus were more likely to have measurement errors than prospective data. In contrast, prospective studies examined the natural course of children's OME experience longitudinally from early infancy, and language development was measured at specified points. Thus, data collection was more likely to be based on objective measurement over time. (See Kleinbaum, Kupper, & Morgenstern, 1982, for a further discussion of issues in timing of data collection.) Research designs. Three research designs have been used in studying the relationship of OME and language development: cohort, case control, and cross-sectional. In the cohort studies, subjects were sampled either from a single population or from more than one population. When a single population was examined (e.g., Fischler et al., 1985; Friel-Patti & Finitzo, 1990; Teele et al., 1984; Wright et al., 1988), a group of children at risk for OME (e.g., all children in a pediatric practice or all children in a day care program) were identified as study subjects, and the incidence of OME within the group was measured and language assessed. When more than one population was examined (e.g., Holm & Kunze, 1969; Schlieper et al., 1985; Silva et al., 1986), the language of children at risk for the OME exposure factor (e.g., ENT clinic patients with a history of OME) was compared to the language of the members of another population not similarly exposed to the OME risk, factor (e.g., pediatric clinic practice without a history of OME). Cohort studies of two populations can be problematic because the ability to make causal inferences between OME and language depend on the assumption that the populations are comparable with respect to all factors other than OME, that is, all confounding factors. However, because it is difficult to know whether the two populations are comparable in regard to other risk factors, these biases can lead to an inaccurate estimate of the relative risk of language problems caused by past occurrence of OME. In the case-control studies (e.g., Brookhouser & Goldgar, 1987; Lehmann et al., 1979; Zinkus & Gottlieb, 1980; Zinkus et al., 1978), subjects were chosen on the basis of whether they had language problems; the OME experience of children with language problems (e.g., clients from a language clinic) is compared to the OME experience of children without language problems. Studies using a case-control design are especially susceptible to biases related to case and control selection. (See Kleinbaum et al., 1982, for further discussion of research designs.) In the third type of design, the crosssectional study (e.g., Allen & Robinson, 1984; Silva et al., 1982), OME experience and language performance were measured at the same time (e.g., at 5 years of age). Cross-sectional studies are not useful in studying the relationship of a history of OME in early childhood to later
Downloaded From: http://jslhr.pubs.asha.org/ by a Northern Illinois University User on 10/03/2016 Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
1160
Journal of Speech and Heanng Research
34
1158-1168
October 199
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Otitis Media in Early Childhood and Later Language Joanne E. Roberts Division of Speech and Hearing Sciences and Frank Porter Graham Child Development Center University of North Carolina at Chapel Hill
Margaret R. Burchinal Department of Psychology and Frank Porter Graham Child Development Center University of North Carolina at Chapel Hill
Brenda P. Davis Frank Porter Graham Child Development Center Unmversty of North Carolina at Chapel Hill
Albert M. Collier Frederick W. Henderson Department of Pedlatncs and Frank Porter Graham Child Development Center University of North Carolina at Chapel Hill
:
The relationship between early otitis media with effusion (OME) experience and later language development was examined in a prospective cohort study of 30 children from middle-class families and 33 children from low-income families. Ear status was monitored using otoscopy and tympanometry during wellness and illness periods between birth and 3 years of age. Language was assessed using standardized tests and a language sample between 41/2 and 6 years Findings suggested no reliable relationship between early OME experience and later language development. KEY WORDS: otitis media, language development, ear Infections, children
Otitis media with effusion (OME), or middle ear disease, is one of the most common illnesses in young children (Teele, Klein, & Rosner, 1980; Teele, Klein, Rosner, & the Greater Boston Otitis Media Study Group, 1989). Recently, speech-language pathologists and audiologists have focused on OME because of a hypothesized linkage between persistent or frequent OME during early childhood and later language difficulties (Holm & Kunze, 1969; Schlieper, Kisilevsky, Mattingly, & Yorke, 1985; Silva, Chalmers, & Stewart, 1986; Teele, Klein, Rosner, & the Greater Boston Otitis Media Group, 1984). The occurrence of fluctuating mild to moderate hearing loss associated with OME during the formative years of language development is assumed to be responsible for these adverse developmental outcomes. The child who experiences changes in hearing sensitivity can receive a partial or inconsistent auditory signal and thus miss or confuse important auditory information. A child with repeated episodes of OME with varying degrees of hearing loss could then experience changes in the input to the database upon which language develops. Despite this conceptually compelling argument, the existence of an association between OME during the first 3 years of life and later language skills remains controversial because of conflicting empirical evidence and methodological problems of studies (Paradise & Rogers, 1986; Ruben et al., 1989; Ventry, 1980, 1983). Numerous studies have found evidence to support the association between early OME and later language development (e.g., Black et al., 1988; Friel-Patti & Finitzo, 1990; Holm & Kunze, 1969; Schlieper et al., 1985; Silva et al., 1986; Zinkus, Gottlieb, & Schapiro, 1978). These studies have shown that children with a history of early OME as compared to children without a history of OME have poorer receptive language (e.g., Pearce, Saunders, Creighton, & Sauve, 1988; Silva, Kirkland; Simpson, Stewart, & Williams, 1982; Teele et al., 1984; Zinkus & Gottlieb, 1980), expressive language (e.g., Friel-Patti & Finitzo, 1990; Rach, Zielhuis, & van den Broek, 1988; Silva et al., 1986; Wallace, Gravel, McCarton, & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988), less diverse vocabulary (e.g., Holm & Kunze, 1969; Teele et al., 1984), less complex syntax (e.g., Holm & Kunze, 1969; Schlieper et al., 1985; Zinkus & Gottlieb, 1980), and different use of language (e.g., Feagans, Sanyal, Henderson, Collier, & Appelbaum, 1987). Language was assessed
1991, American Speech-Language-Hearing Association
1158
Downloaded From: http://jslhr.pubs.asha.org/ by a Northern Illinois University User on 10/03/2016 Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
70224685/91 /345-1158$01 .00/C
Roberts et al.: Ontis Media and Language
using standardized language tests (e.g., Friel-Patti & Finitzo, 1990; Silva et al., 1982; Wallace, Gravel, McCarton, & Ruben, 1988), language samples (e.g., Schlieper et al., 1985; Teele et al., 1990), and parent report of language development (e.g., Zinkus & Gottlieb, 1980; Zinkus et al., 1978). A relationship between OME and language was reported for infants and toddlers (e.g., Friel-Patti & Finitzo, 1990; Friel-Patti, Finitzo-Hieber, Conti, & Brown, 1982; Wallace, Gravel, McCarton, & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988), preschool children (e.g., Lehmann, Charron, Kummer, & Keith, 1979; Pearce et al., 1988; Rach et al., 1988; Schlieper et al., 1985), and schoolaged children (e.g., Silva et al., 1986; Teele et al., 1990; Zinkus & Gottlieb, 1980; Zinkus et al., 1978). However, other studies failed to support a relationship between early OME and language skills (e.g., Allen & Robinson, 1984; Fischler, Todd, & Feldman, 1985; Lous, FiellauNikolajsen, & Jeppesen, 1988; Wright et al., 1988). Children with a history of OME did not score more poorly than children without a history of OME in receptive language (e.g., Black et al., 1988; Rach et al., 1988; Teele et al., 1990; Wallace, Gravel, McCarton & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988; Wright et al., 1988), expressive language (e.g., Black et al., 1988; Pearce et al., 1988; Silva et al., 1982; Wright et al., 1988), vocabulary (e.g., Brookhouser & Goldgar, 1987; Fischler et al., 1985; Lous et al., 1988; Wright et al., 1988), and syntax (e.g., Feagans et al., 1987; Fischler et al., 1985; Teele et al., 1984). Assessments were made using standardized language tests (e.g., Fischler et al., 1985; Lous et al., 1988; Wright et al., 1988) and language samples (e.g., Feagans et al., 1987; Teele et al., 1990). Children in the studies were infants and toddlers (e.g., Black et al., 1988; Wallace, Gravel, McCarton, & Ruben, 1988; Wallace, Gravel, McCarton, Stapells, et al., 1988), preschoolers (e.g., Pearce et al., 1988; Rach et al., 1988; Wright et al., 1988), and school-aged children (e.g., Fischler et al., 1985; Silva et al., 1982; Teele et al., 1990).
Explanations of Conflicting Findings The conflicting findings in the studies of the relationship between early OME and later language performance may be due to two things: (a) limitations in the methodologies of previous studies (Paradise, 1981, 1983; Paradise & Rogers, 1986; Ruben et al., 1989; Ventry, 1980), in particular the timing of the data collection, research design, and OME documentation procedures; and (b) interactions between OME and other risk factors (Roberts & Schuele, 1990). Table 1 describes previous OME-language studies according to these methodological issues. Methodological Issues Timing of data collection. In the OME-language studies, data were collected either prospectively or retrospectively. In a completely prospective study (e.g., Fischler et al., 1985; Friel-Patti & Finitzo, 1990; Pearce et al., 1988; Teele et al., 1984), from the onset of the study the researcher observed both the OME history and the language of the children;
1159
neither was observed before the beginning of the study. In contrast, in a completely retrospective study, both the OME and language outcomes have occurred before the study began. Some studies combined both retrospective and prospective methods and use an ambispective approach (e.g., Black et al., 1988; Holm & Kunze, 1969; Schlieper et al., 1985); the OME history was collected retrospectively and the language outcomes prospectively. Data in retrospective studies were generally collected through recall of past events or a review of records, and thus were more likely to have measurement errors than prospective data. In contrast, prospective studies examined the natural course of children's OME experience longitudinally from early infancy, and language development was measured at specified points. Thus, data collection was more likely to be based on objective measurement over time. (See Kleinbaum, Kupper, & Morgenstern, 1982, for a further discussion of issues in timing of data collection.) Research designs. Three research designs have been used in studying the relationship of OME and language development: cohort, case control, and cross-sectional. In the cohort studies, subjects were sampled either from a single population or from more than one population. When a single population was examined (e.g., Fischler et al., 1985; Friel-Patti & Finitzo, 1990; Teele et al., 1984; Wright et al., 1988), a group of children at risk for OME (e.g., all children in a pediatric practice or all children in a day care program) were identified as study subjects, and the incidence of OME within the group was measured and language assessed. When more than one population was examined (e.g., Holm & Kunze, 1969; Schlieper et al., 1985; Silva et al., 1986), the language of children at risk for the OME exposure factor (e.g., ENT clinic patients with a history of OME) was compared to the language of the members of another population not similarly exposed to the OME risk, factor (e.g., pediatric clinic practice without a history of OME). Cohort studies of two populations can be problematic because the ability to make causal inferences between OME and language depend on the assumption that the populations are comparable with respect to all factors other than OME, that is, all confounding factors. However, because it is difficult to know whether the two populations are comparable in regard to other risk factors, these biases can lead to an inaccurate estimate of the relative risk of language problems caused by past occurrence of OME. In the case-control studies (e.g., Brookhouser & Goldgar, 1987; Lehmann et al., 1979; Zinkus & Gottlieb, 1980; Zinkus et al., 1978), subjects were chosen on the basis of whether they had language problems; the OME experience of children with language problems (e.g., clients from a language clinic) is compared to the OME experience of children without language problems. Studies using a case-control design are especially susceptible to biases related to case and control selection. (See Kleinbaum et al., 1982, for further discussion of research designs.) In the third type of design, the crosssectional study (e.g., Allen & Robinson, 1984; Silva et al., 1982), OME experience and language performance were measured at the same time (e.g., at 5 years of age). Cross-sectional studies are not useful in studying the relationship of a history of OME in early childhood to later
Downloaded From: http://jslhr.pubs.asha.org/ by a Northern Illinois University User on 10/03/2016 Terms of Use: http://pubs.asha.org/ss/rights_and_permissions.aspx
1160
Journal of Speech and Heanng Research
34
1158-1168
October 199
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0
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-J w zZ
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0
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.5= Ci)
